Malaria Situation in a Clear Area of Iran: an Approach for the Better
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Azizi et al. Malar J (2020) 19:114 https://doi.org/10.1186/s12936-020-03188-7 Malaria Journal RESEARCH Open Access Malaria situation in a clear area of Iran: an approach for the better understanding of the health service providers’ readiness and challenges for malaria elimination in clear areas Hosein Azizi1,2*, Elham Davtalab‑Esmaeili2, Mostafa Farahbakhsh2, Maryam Zeinolabedini3, Yagoub Mirzaei4 and Mohammad Mirzapour5 Abstract Background: Malaria mortality and morbidity have decreased in recent years. Malaria elimination (ME) and efective eforts to achieve ME is one of the most important priorities for health systems in countries in the elimination phase. In very low transmission areas, the ME programme is faced with serious challenges. This study aimed to assess the trend while getting a better understanding of Health Service Providers’ (HSPs) readiness and challenges for ME in a clear area of Iran. Methods: This study was performed in two phases. At frst, the malaria trend in East Azerbaijan Province, was sur‑ veyed from 2001 to 2018; afterward, it was compared with the national situation for a better understanding of the second phase of the study. Data were collected from the Ministry of Health’s protocol and the health centre of the province. In the second phase, malaria control programme experts, health system researchers, and health managers’ opinions were collected via in‑depth interviews. They were asked regarding HSPs readiness and appropriate Malaria Case Management (MCM) in a clear area and possible challenges. Results: A total of 135 and 154,560 cases were reported in the last 18 years in East Azerbaijan Province and Iran, respectively. The incidence rate decreased in East Azerbaijan Province from 0.4/10,000 in 2001 to zero in 2018. Further‑ more, no indigenous transmission was reported for 14 years. Also, for the frst time, there was no indigenous transmis‑ sion in Iran in 2018. The main elicited themes of HSPs readiness through in‑depth interviews were: appropriate MCM, holistic and role‑playing studies for assessment of HSPs performance, system mobilization, improving identifcation and diagnosis of suspected cases in the frst line. Similarly, the main possible challenges were found to be decreas‑ ing health system sensitivity, malaria re‑introduction, and withdrawing febrile suspected cases from the surveillance chain. Conclusion: Health systems in eliminating phase should be aware that the absence of malaria cases reported does not necessarily mean that malaria is eliminated; in order to obtain valid data and to determine whether it is *Correspondence: [email protected] 1 Department of Epidemiology and Biostatistics, School of Health, Tehran University of Medical Sciences, Tehran, Iran Full list of author information is available at the end of the article © The Author(s) 2020. 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The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/ zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Azizi et al. Malar J (2020) 19:114 Page 2 of 10 eliminated, holistic and role‑playing studies are required. Increasing system sensitivity and mobilization are deemed important to achieve ME. Keywords: Challenges, Elimination, Iran, Malaria, Readiness, Health service provider Background understood. Tus, advances in understanding local According to the World Health Organization (WHO) and up-to-date information about malaria trends and report in 2018, malaria mortality and morbidity have situations in clear areas are essential for the National decreased in recent years [1]. In 2017, the number of Malaria Control Programme and health policymak- malaria deaths was reduced from 607,000 to 435,000 ers in countries in the elimination phase. Another aim compared to 2010, also, during these years the global of this study is to assist policymakers in better under- incidence rate of malaria reduced from 72 to 59 cases per standing of system readiness and challenges for ME 1000 population at risk [2]. Many countries in the world as well as adopting an appropriate strategy to adjust made substantial progress in malaria elimination (ME). barriers and challenges in clear areas [14]. Hence, the Te WHO has defned that ME is the interruption of present study aimed to investigate HSPs readiness and indigenous transmission of a specifed malaria parasite challenges for ME and malaria trends in East Azerbai- species in a defned geographic area; continued measures jan Province from 2001 to 2018. are required to prevent re-establishment of transmission [3, 4]. In Iran, during the last decades, malaria has been the Methods most important infectious disease with about 1500 cases Study design per year, especially, in southern and southeastern areas Tis study was performed in East Azerbaijan Prov- [5, 6]. ME was started with political commitment, inter- ince, northwest of Iran in which no Indigenous malaria sectional collaboration, and evidence-based research in case has been reported for 15 years (from 2005). Tis 2009 and Iranian health system is planning for ME certi- study was composed of two sections. In the frst sec- fcation in 2025 [7]. During the last decades, vector con- tion, malaria trend was investigated from 2001 to 2018 trol interventions as well as many efective eforts have in East Azerbaijan Province, an area of Iran considered been done for malaria control including enlarged cover- cleared of malaria. age of integrated vector management (IVM), using rapid In section two, 6 in-depth interviews were conducted diagnostic tests (RDTs), appropriate case management, with two malaria feld experts (one with master’s degree training of microscopists and Health Service Providers and the other a medical doctor), who monitored and (HSPs), and developing a malaria early warning system supervised malaria control programme, two were vice [7–9]. For the frst time, zero indigenous case reported managers and the other two were researchers with in Iran in 2018. A large amount of efective eforts, envi- PhD in health system from Tabriz University of Medi- ronmental measures, and proper case management were cal Sciences. In Iran, medical universities are responsi- conducted for malaria control in Iran [10]. ble authorities for the health system in each province. In clear areas and countries in elimination phase, Te Iranian health system is composed of three levels system readiness, an appropriate malaria case manage- based on referral system; the frst level is primary level ment (MCM), such as identifcation, diagnosis, appro- of health services to access all urban and rural popula- priate treatment and urgent report of malaria cases to tions by family physicians and various types of HSPs. the public sector, and system vigilance were decreased When patients need special health services, they are [11]. In these areas, the management of suspected referred to the second level (county hospitals) by family malaria or febrile cases is defective due to the very low physicians, and when high special services are required, or absence of malaria transmission [12, 13]. Terefore, patients are referred to province referral hospitals with the sustainability of elimination status and appropriate high special services [15, 16]. It is worthwhile to men- MCM are necessary for pre-elimination. Based on the tion that in Iran all malaria control services in the pub- province malaria department data in northwest of Iran, lic sector such as diagnosis and treatment of malaria East Azerbaijan Province, the indigenous transmission cases are free and anti-malarial drugs are available only has been absent for 14 years and imported cases were in the public sector in the frst referral level. Te public very few. However, it seems that in clear areas, malaria sector is responsible for malaria control in Iran. Not to surveillance and HSPs readiness statuses are poorly mention that private sector has to report any identifca- tion of a suspected malaria case to public sector. Azizi et al. Malar J (2020) 19:114 Page 3 of 10 Defnitions the national situation for a better understanding of the Health service providers (HSPs) are primary health care Iranian malaria situation and malaria elimination pro- practitioners who visit people with common medical gramme goal with planning for elimination in 2025 and problems. HSPs are the frst line providers whom sus- receiving ME certifcation which is awarded for national pected malaria cases referred in the frst step. Tese geographical level. Fortunately, in most Iranian prov- providers comprised of emergency physicians, family inces, there is no indigenous malaria transmission. physicians, general practitioners, public or private sector Hence, the main objective of this study is to assess the specialists (in health centres, hospitals, and clinics), phar- HSPs readiness for ME in specifc regions (East Azerbai- macists, health workers, and health care providers in cit- jan Province) of Iran and to understand the challenges ies and villages. associated with ME in general. HSPs readiness in this study, readiness is relevant to HSPs practice and performance in the management In‑depth interviews of patients with a history compatible with suspected Te face to face in-depth interviews were conducted with malaria.